优化老年患者胸部手术围手术期管理策略的临床研究

Optimized perioperative management helps improve the results of thoracotomy in elderly patients

目的通过优化老年患者开胸手术围手术期管理模式提高手术疗效。方法对58例≥65岁开胸手术患者进行前瞻性围手术期呼吸、循环监测，观察术后并发症发生情况，并与同期56例〈65岁患者对照。在此基础上建立优化围手术期管理模式，前瞻性治疗179例≥65岁病例，并与同期477例非老年病例比较。结果后期优化管理组老年病例术后住院病死率（4．9％vs.1．1％，P=0．033）及总体并发症发生率（58．6％ vs．21．8％，P〈0．01）均明显低于前期监测研究组，尤其是以心血管和呼吸为主的功能性并发症发生率明显降低（51．7％ vs．14．5％，P〈0．01），而外科操作性并发症发生率无明显差异。与前期监测研究组相比，后期优化管理组急性肺损伤（17．2％vs.6．7％，P=0．016）和呼吸衰竭发生率（6．9％vs．1．7％，P=0．041）均下降；术后早期心律失常发生率亦有降低（20．7％vs．7．3％，P=0．004）。结论通过深入术前功能评估、加强手术麻醉中保护性肺通气、术后严格控制液体出入量以及及时的介入性呼吸循环管理、优化老年患者的围手术期管理模式，可明显提高老年患者胸部手术的疗效。

Objectives To optimize perioperative respiratory and circulatory management so as to improve the surgical results of thoracotomy in elderly patients. Methods Respiratory and circulatory status was prospectively monitored and postoperative complications were documented in 58 elderly patients aged over 65 years underwent thoracotomy. The results were compared with those from 56 young patients aged under 65 years in the same time period. Based on the study results, the original perioperative management model was modified and prospectively studied in the following 179 elderly patients. Again the results were compared with 477 younger patients concomitantly treated. Results Through optimized perioperative management, the in-hospital mortality （4. 9% vs. 1.1% , P =0. 033） and overall morbidity （58. 6% vs. 21.8% , P 〈 0. 01 ） were significantly decreased. This was most significant in the decrease of functional complications （51.7% vs. 14. 5%, P 〈 0. 01 ）, especially the cardiovascular （ 22. 4% vs. 7.3%, P = 0. 001 ） and respiratory complications（20. 7% vs. 7. 3%, P =0. 004）. There was no difference in technical complications between the two time periods. Comparing with the original model, the optimized perioperative management strategy resulted in significant decrease in acute lung injury （17. 2% vs. 6. 7%, P =0. 016）, respiratory failure （ 6. 9% vs. 1.7% , P = 0. 041 ） , as well as cardiac arrhythmia （ 20. 7% vs. 7.3% , P = 0. 004） in the early postoperative period. Conclusions Optimization of perioperative management through careful preoperative functional evaluation, intraoperative protective ventilation, postoperative close monitoring of water balance, and timely intervention, may help improve surgical results in the elderly.